If a drug your doctor prescribes is not on our formulary, or if the drug is subject to one of our Utilization Management requirements, such as step-therapy or quantity limits, you or your doctor can request a Formulary Exception. A non-formulary drug that we approve through the Formulary Exception Process will be considered a non-preferred brand drug on Tier 3.
If your drug is a non-preferred brand-name formulary drug (Tier 3) and you believe it should be available for the preferred brand-name copay (Tier 2), you or your doctor can request a Tiering Exception. Please note that a Tiering Exception is not available for specialty (4th Tier) drugs, nor can the exception process be used to get a brand-name drug for the generic (1st Tier) copay. You may not request a Tiering Exception for a non-formulary drug that we have approved through the Formulary Exception Process.
Making an exception request
When you request an exception to the plan’s formulary or tiering structure, your physician must provide a “physician supporting statement.” To do so, your physician may use one of the following forms (requires Adobe Reader):
The prescribing physician must sign the completed form and send it, with appropriate documentation of medical necessity, to:
Health Alliance Plan
C/O Medimpact Healthcare Systems, Inc
Attn: Prior Authorization Department
10680 Treena Street, Suite 500
San Diego, CA 92131
If we approve your request, the approval will remain in effect for 12 calendar months (so long as your doctor continues to prescribe the drug and it continues to be considered safe and effective).
If we deny your request, you have the right to request an Appeal.